Age estimation in non-adults Age determination using teeth: history and state of the art Prof. Vilma Pinchi

1. Institute of Legal Medicine University of Macerata FASE Meeting 2007 Age estimation , state-of-the-art, guidelines and new projects Macerata, 5-6 October 2007 Age estimation in non-adults Age determination using teeth: history and state of the art Prof. Vilma Pinchi University of Firenze Dept.Sec. Legal Medicine Dir. Prof. Gian-Aristide Norelli

2. Age determination in living - What principal causes Immigration Increasing of criminality in childhood and adolescence Degree of imputability? Subject without documents or valid documents No decisive contacts with the Country of provenance of the subject University of Firenze Dept.Sec. Legal Medicine

3. Age determination in living - What demands • The most frequent demands of age determination are related to : • The assessment of imputability degree • Proceedings for asylum • Less frequent demands of age determination are for: • The correct attendance of the school (of adopted and undernourished children) • Subjects that have lost memory (to whom Italian law allows to re-build a new identity) • Old-age pension proceedings (no known cases in Italy) University of Firenze Dept.Sec. Legal Medicine

4. Legal thresholds of age • 14 and 18 are the most diffused • mostly range from 14 to 21 years • In Italy: 14 and 18 are the legal thresholds for subject legal chargeability even if 16 has some importance for civil proceedings • Age determination in non-adults: developing teeth contribute • Eruption of teeth • Calcification / formation of teeth University of Firenze Dept.Sec. Legal Medicine

5. Formation of the teeth and the available methods Numerous Authors have proposed classifications to grade the dental formation and methods to assess age Gustafson e Koch (4 stages ,1974), Harris and Nortje (5 stages, 1984), Kullman(7 stages, 1992) Demirjian (8 stages, 1973,1976) , Liliequiest (8 stages,1971), Solari (10 stages, 2002) , Kohler(10 stages, 1994), Nolla (11 stages, 1960), Haavikko ( 12 stages , 1970-1974),Portigliattiand Robetti (13 stages,1982-1984), Moorees (14 stages, 1963) Gleiser and Hunt (15 stages, 1955) Demirjian’s method is undoubtedly the most widespread and represents a sort of constant comparison for all researchers

6. Scientific literature - Comparison of results • It is difficult to compare the results obtained from different Authors because of the different populations (size, distribution, ethnic origin, etc.), the stage classification, the statistical analysis of the data, etc. • It is useful to compare separatelyresearches, that consider teeth except third molar and researches that include or study exclusively the third molar, because: A- there is consistent evidence regarding the different behavior of the third molar calcification with respect to other teeth (higher variability, different influence of sex and ethnicity on wisdom tooth development compared to other teeth, i.e.). B- for the most diffused legal threshold ages of 14 and 18, the dentition up to the 2nd molar and the third molar assume respectively the highest importance. • When the comparison involves the original method of Demirijan, it shouldn’t be forgotten that: • A- The Demirjian method was elaborated not for assessing age, but for clinical purposes (to indicate to the dentist the degree of dental development of a child of known age) • B- The original percentile curves go back to the seventies University of Firenze Dept.Sec. Legal Medicine

7. Dentition up to 2° molar - Demirjian method • it is generally accepted that the original method of Demirjian produces an overestimation of age when applied to different populations with respect the French-Canadian population • The original percentile curves have been adjusted for some populations (i.e for Belgian by Willems and for Finnish by Kataja). The adjusted standards have shown higher reliability. • Furthermore there is a consistent opinion that retains the percentile curves more appropriate for clinicians to asses the dental maturity (of a subject of known age) than for assessing age (of the subject on the base of his/her dental development stage). Polynomial functions are often recommended • The Demirjian’s classification of stages is often appreciated because of the contained number of stages and their clear description based upon morphological change and not upon root length fractions.

8. Dentition up to the 2nd molar - 14 threshold age • it is well known that the determination of age becomes more difficult and less accurate with the aging of the children and it is generally assumed that the assessment of 14 and 16 thresholds are easier than 18 and over. • As noted by Cingolani, Cameriere et Al. few studies are specifically addressed to assess if a probant has attained the age of 14. These Authors propose new and interesting methods based on some measurements of tooth on OPG (pulp/tooth area ratio for the second molar, measurement of open apices of third molar,etc.) that provide age estimations endowed with higher probability and with not significant differences for Italian, Slovenian and Croatian populations University of Firenze Dept.Sec. Legal Medicine

9. Third molar development – some points • The classification of Demirjian is often chose or recommended by researchers with respect to other classification systems (De Salvia et Al., Liversidge et Al Olze, Pinchi et Al., Prieto et Al., Schemling et Al, , etc.) • For the interarches variability it is generally accepted that there are no significant and recurrent differences for side (right-left), whereas some researches have shown the maxillary third molars more advanced than the mandibular opposites • Testing the difference of third molar mineralization between sexes, the most common and shared findings, also for different populations, are that the boys are more advanced respect to girls. • Some Authors (Olze, Schemling, Koeler et Al)seem to accept that the inclusion has a slowing effect on the formation, whereas Friedrich has noticed no influence of ten different kinds of impaction on the velocity of root development. University of Firenze Dept.Sec. Legal Medicine

10. Age estimation – questioned points The influence of pathologies, nourishment, environment,etc. There are valuable reports about the influence (or not influence) of some congenital pathologies, hormone deficiency, etc. but these researches are necessarily limited to small population samples. • The decision of odontologist/dentist entrusted by the judge: • to visit the subject and to examine the available medical files or • not to visit, but eventually to examine only the available medical file or • not to visit, not to examine medical files. The age determination is based exclusively on dental X-rays • The decision of researchers: • to include only healthy children in their study • to include all subject without regard to the general health status University of Firenze Dept.Sec. Legal Medicine

11. Age estimation – questioned points The influence of ethnicity • the influence of ethnicity could be limited to third molar calcification and seems not relevant for dentition up to the second molar. Furthermore, also for the third molar, the influence of ethnicity seems limited to the crown formation and sometimes it is apparent.(Liversidge et Al.., Mincer et Al., etc.). • There are consistent differences in third molar development between Blacks, Caucasoid and Mongoloid subjects(Mincer et Al., Harris et Al., Schemling, Olze et Al,etc.). • Caution is expressed about results because: • It is difficult to study the ethnic influence separately from the socio-economic status,enviroment,etc. • Some variability might be due to the, at least partial, inappropriateness of the statistical methods University of Firenze Dept.Sec. Legal Medicine

12. Age estimation – questioned points The higher variability of the practical approach Guidelines -the method must be transparent and provable, the underlying data must have presented to scientific community as a rule by publication in peered-review journals.. -Clear information concerning the accuracy of age estimation by the method should be available… -the methods need to be accurate enough to fulfill the specific demands of the single case to solve the underlying questions… -in cases of age estimation in living individuals principles of medical ethics and legal regulation have to be considered, especially if medical intervention is involved ...omissis Ritz-Timme, Cattaneo et Al, -physical examination of the subject with determination of anthropometric measures (height, weight, etc.) inspection of sexual maturation and eventual developmental disorders that could have affected the dental maturation -X-ray examination of the left hand -examination by a dentist with determination of the dental status and X-ray study of the dentition …omissis.. AGFAD Black indicates required steps - Blue indicates recommended steps. (may be omitted or changed without further explanation) General -The purpose of the age estimation is to 1. estimate the most likely age of the individual 2. make references to the methods used 3. express the likelihood of an official age, if it exists 4. express the likelihood of an alternative age, if it exists,…. omissis IOFOS

13. Age estimation of non-adults in Italy In Italy the practical approach to age estimation in non-adults is very inhomogeneous, sometimes varies from a judge to another in the same Court Often the judge obtains an age estimation based exclusively on wrist-hand x-rays, sometimes from a radiologist of an emergency room or worse from a physician on physical examination of the subject • The relatively recent development of the forensic odontology as autonomous discipline • The judge is used to entrust only an expert for the skeletal age • The courts not always seem to realize the complexity of the age assessment that is time consuming and requires a high availability to experts • Few odontologists or dentists in Italy can specifically and continuously dedicate themselves to the practice of age determination for living persons, whereas others are limited to the theoretical knowledge of methods University of Firenze Dept.Sec. Legal Medicine

14. Age estimation The procedure of Legal Medicine Institute of Florence The collaboration with the judge • In all cases we require the entrustment of a team composed of an experienced forensic odontologist and a specialist in legal medicine . If judge doesn’t comply the task is refused: neither dentist or legal medicine specialist wants to give an expert witness about a matter different from his own • We recommend to the judge not to require any exams of the subject (physical, Xrays, etc.). We experienced some errors as unnecessary x-rays, x-rays of poorer quality respect to those usually obtained, radiographic examination of girls before asking/knowing their pregnant status. University of Firenze Dept.Sec. Legal Medicine

15. Age estimation The procedure of Legal Medicine Institute of Florence The examination of the subject • The two experts perform the visit together : • Physical examination • An anamnesis is required to the subject, (including his/her general health status, information about family, school attendance, job, etc.) Many times the subject has/tells to have linguistic difficulties We set out two questioners for ages of 14 and of 18 translated in different languages University of Firenze Dept.Sec. Legal Medicine

16. Age estimation The procedure of Legal Medicine Institute of Florence The questioner • An introduction that explains the scope of the physical examination and of x-ray exams and warns girls to communicate the eventual pregnant status • 20-25 questions about actual and past general health status, important pathologies of relatives, school attendance, job, time of arrival in our Country, etc. • Advantages: • The validity of the collected information is higher • Great importance from the ethics point of view for the examiners that strongly want to inform the minor • The judge has the possibility to render the questioner official • Results (questioners translated in Arabian and Rumanian): • The subjects answer to all questions • The time of anamnesis collection is halved University of Firenze Dept.Sec. Legal Medicine

17. Age estimation – the procedure of Legal Medicine Institute of Florence Visit and anamnesis collection separately legal medicine specialist odontologist Physical features X-rays of wrist-hand Skeletal age Dental features OPG Dental Age • A- For estimating both skeletal and dental age, two different methods are used : • For wrist-hand bones: Nicoletti’s and FELS method for age of 14 and Tanner’s and Fels methods for 18 • For teeth :the methods are chosen considering the ethnic origin. For age of 18, ALL available third molars are considered • B- The immaturity signs weight on the final estimation of age more than the maturity features (more adherent to ethics and legal demands) • Legal medicine specialist<< together >>Odontologist • 1st- Compare the estimated ages (skeletal and dental) • 2nd - Write a report to the judge that contains: • The estimated ages and the connected errors. Some details about the method are underlined • likelihood of the age declared by the subject • likelihood for the subject to have reached the legal threshold age of interest.